POLÍTICA INTEGRAL DEL PROYECTO

medically treated.⁵⁸ The stress response helped us respond instantaneously to acute threats such as predation and is now activated on a persistent basis via work deadlines, credit card debt, and road rage.⁵⁹ Ultimately, the consequence of adaptability, social dominance, and developmental plasticity is that the human body and brain is highly susceptible to the conditions of its social environment (which includes being

manipulation, illusion, deception, guidance, suggestion, and circumstance).

I am trying to convey two main points in this section. First, social adaptations in our evolutionary history have made us more physically susceptible to the cues, threats, and conditions of our social environments. And, second, when triggered continuously (as happens often nowadays), they can actually cause or exacerbate sickness and disease.⁶⁰ The latter is particularly significant because medical therapies that are able to mediate social cues and conditions or lessen the occurrence and course of these types of social adaptations can influence the processes of sickness and healing. Understanding the evolutionary development and proximate mechanisms of social susceptibility helps us to see that part of the therapeutic efficacy of indigenous medicine is regulating these systems through action on social relationships and meaning.

2.3 The Evolutionary Processes of Social Susceptibility

There are specific evolutionary transitions and adaptations that leave human bodies susceptible to social cues, threats, and conditions. Due to space constraints, I provide a

58 See Chapter 5: Emotion for more on this.

59 See Chapter : Stress for more on this.

60 For example, stress inhibits the immune system. If it persists a long time it can leave the body vulnerable to bacteria, viruses, and harmful pathogens. It is also a predictor of: obesity, heart disease, diabetes, and hypertension.

detailed discussion and literature review of the following social susceptibility ecological, social, and morphological transitions in human phylogenetic history in Appendix:

Chapter 2: 2.6 The Evolutionary Processes of Social Susceptibility:

● Benefits and Costs of Group Living (2.6.1)

● Social Versus Ecological Determinants of Brain Size (2.6.2)

● Social Brain Hypothesis (2.6.3)

● Challenges from Encephalization and Increased Life History Demands (2.6.4)

● Hyper-Attachment Adaptations (2.6.5)

● Social Selection (2.6.6)

● Developmental Plasticity (2.6.7)

● Genome, Epigenome, Epigenetics (2.6.8) 2.4 Evolutionary Medicine

“Unfortunately, much of modern medical practice demonstrates a misunderstanding of the evolution of physical responses to stresses that were faced by our ancestors”

(Trevathan et al. 1999: 2). This is one of the biggest problems facing medical researchers and practitioners today. The previous sections in this chapter set out to explain how and why our bodies evolved to be highly responsive to stressors in our social world, which created the conditions in which developmental and behavioral plasticity rapidly expanded. The ability to perceive the world and respond in fitness enhancing ways via one’s physical senses, or physical susceptibility to social triggers, was selected for because it encouraged pro-social and discouraged anti-social behavior. While all of these social susceptibility adaptations were advantageous to our survival and reproduction in the Pleistocene and led to our overwhelming success as a species, they also result in evolutionary trade-offs and mismatches with modern environments that are harmful to our health (See Appendix: Chapter 2: 2.10.6 Modern Mismatches of Social Susceptibility for a deeper discussion on evolutionary mismatches in modernity). They leave our bodies

susceptible to psychosocial intervention. This knowledge is the foundation from which we can build a better understanding of the sophisticated biocultural interactions at work in mind-body medicine.

In The Social Life of Placebos, I want to show that key features of Asante indigenous ritual healing ceremonies are well suited to counteract some of the health problems exacerbated by social susceptibility. Because many of the stressors faced by the Asante are culturally specific (e.g., witchcraft and familial obligation), healthcare that target those specific psychosocial etiologies themselves, and not just the biological symptoms, can impact the healing processes.

“Cultural ideologies, values, and the socialization experiences of medical researchers often prevent disease and human disorders from being conceptualized in evolutionary terms, even in the face of much relevant data that make it necessary and logical”

(Trevantan et al. 1999:5-6). Evolutionary medicine uses a more holistic framework that analyzes the development of the brain and body, incorporating phylogenetic trajectories and the selective pressures of ecology and sociocultural niche construction. It “involves the application of evolutionary theory to understand…diseases in the past and…what they may tell us about contemporary health issues” (Brown 1998:2-3).

Since all human societies have had to cope with sickness and healing as well as social susceptibility, research particularly focused on culturally constituted stressors and

methods of alleviation (or, arguably, ways that the stressor-alleviation cycle is

continually reinforced) via medical rituals represents a rich field of study, creating “a

feedback loop from behavior to environment to selection in ways that are not generally represented in most evolutionary scenarios” (Downey and Lende 2012:118).

The mechanistic model of modern biomedicine represents the body as a machine—a system of processes, interactions, and connections that can be analyzed, broken apart, and put back together. While this approach to medicine has proven effective in many areas, it is not a very realistic portrayal of the human body. Individual machines are devoid of history, variety, culture, or community. They don’t yet adapt to circumstances, have expectations, exhibit individual temperaments, respond to environmental changes, or mimic other machines. Another theoretical model is that of evolutionary medicine. This perspective represents the human body (as well as pathogens) as the result of millions of years of small adaptations to environmental pressures where variation in any given trait (including genotypic, phenotypic, and epigenetic, as well as psychological, social, and cultural) within a population leads to differential fitness where those traits most suited to a particular environment (or sexually selected for) survive and reproduce at higher frequencies in subsequent generations. Since sickness and disease are problems that have existed throughout evolutionary history all organisms have had to develop adaptive responses to those problems.

Evolutionary medicine⁶¹—which “involves the application of evolutionary theory to understanding diseases in the past and to understanding what they may tell us about contemporary health issues” (Brown 1998:2-3)— incorporates the ecological, historical

61 Go to Appendix: Chapter 2: 2.7 Evolutionary Medicine for more. This has also been called Darwinian medicine, dual inheritance theory, and gene-culture co-evolution.

and sociocultural environments and interactions in which sickness and disease develop and the sociocultural adaptations and technologies that have evolved to maintain health and wellbeing over time. In the last decade, researchers have begun to uncover the biocultural evolutionary determinants of health and the modern ecological mismatches of many other health problems.⁶² This field incorporates evolutionary knowledge in order understand and treat sickness and disease in modern health contexts and explores motivating and constraining influences on the human body’s physiological response to disease over time and to therapeutic behaviors across cultures.⁶³

2.4.1 Evolutionary Medicine of Medical Therapy

The application of biocultural evolutionary theory “use[s] evolutionary models to examine both the physiological responses of the human host to a disease organism and the physiological responses to medical therapies” (Brown 1998:3). It is important to highlight that research in evolutionary medicine (and even paleo and biological anthropology)⁶⁴ has been overwhelmingly focused on the former aspect, the evolution and physiological response to disease, and has largely neglected the latter aspect, the

62 Such as: addiction (Smith 1999; Lende 2007), allergies (Barnes et al. 1999), anxiety and mood disorders (Neese 2011), asthma (Hurtado et al. 1999), back pain (Anderson 1999), breast cancer (Eaton and Eaton III 1999), colic (Barr 1999), chronic degenerative diseases (Gerber and Crews 1999; Ewald 2007), congestive heart failure (Weil 2007), lactose intolerance (Wiley 2007), depression (Neese 2009), diabetes (Moalem 2007; Lieberman 2007), eclampsia/preeclampsia (Robillard et al. 2007), malaria (Moalem 2007), neonatal jaundice (Brett and Niermeyer 1999), premenstrual syndrome (Doyle et al. 2007), infertility (Nunez-de la Mora and Bentley 2007; Pollard and Unwin 2007), and sexually transmitted diseases (Ewald 1999; Foxman and Neese 2011).

63 See Appendix: Chapter 2 2.7 Evolutionary Medicine for more on this topic.

64 For example, “Paleoanthropology can provide a window on disease evolution over long periods of time and highlight the main reasons for the appearance of specific diseases” (Roberts and Manchester 2005; see also Larsen 1997). “Biological/medical anthropology focused on living populations can provide a better context for the many factors responsible for disease occurrence in populations today” (McElroy and Townsend 1996; Sargent and Johnson 1996).

physiological response to medical therapy. This is my biggest criticism of the field. It has not paid adequate attention to role of medical systems in influencing our socially

susceptible bodies. This is a major oversight because highly plastic, hyper-reactive, context dependent brains and bodies provide an ideal lens, especially when combined with extensive ethnographic specificity, into psychosocial-physiological mutual reactivity; or how social and cultural things get under the skin.

While most research in this area focuses on the evolutionary mechanisms of illnesses and disease or the mismatch between our stone-age bodies and modern environments, this manuscript highlights a less explored aspect of evolutionary medicine that focuses on the evolutionary roots of culturally specific medical behaviors, beliefs, expectations and therapies; to focus not only on the illness itself, but on how people have coped with sickness and disease over time and across cultures. Furthermore, because of human developmental plasticity and social susceptibility, scientists better equipped via evolutionary models to recognize and evaluate the influence of social and cultural behaviors and expectations on the body “can draw on the increasing evidence of how neuroplasticity plays a role in social and cultural dynamics” (Lende and Downey 2012:24).

In fact, the most renowned books on evolutionary medicine during the last twenty years⁶⁵ focus almost exclusively on disease and largely ignore ethnomedical therapies and physiological responses to medical therapy. One rare exception is an article on

65 Neese and Williams 1996; Ewald 1996; Trevathan et al. 1999; Boaz 2002; Sapolsky 2004; Moalem 2007; Stearns and Koella 2008; McKenna et al. 2008; O’Higgens and Elton 2008; Trevathan and McKenna 2008; Gluckman et al. 2009

“Evolutionary Paediatrics” by Helen Bell in O’Higgins and Elton’s 2008 book Medicine and Evolution in which Bell describes the field of ethno-pediatrics, which compares parent-infant behavior cross-culturally in order to discover how different caregiving styles impact health and disease in children. Bell then combines both ethno-pediatric and evolutionary medicine to argue for an evolutionary pediatric “approach to infant and child health that draws upon cross-species, cross-cultural, historical, and

palaeoanthropological evidence to inform critical examination of Western postindustrial and biomedical models of infant care” (Bell 2008:128).

The Social Life of Placebos attempts to fill in the lacuna left by evolutionary medicine’s neglect of biocultural evolutionary analyses of ethnomedicine and medical therapies. I want to follow Bell’s model and argue for an “evolutionary ethnomedicine”

which compares medical therapies cross-culturally in order to discover how different practices affect health, wellbeing and survival.

What would an evolutionary medicine approach to medical therapies look like? First, it would assume that all medical systems, including biomedicine and all medioreligious practices worldwide that deal with sickness and healing, are “ethnomedicines”⁶⁶— where

“disease is a construct created and reproduced by any/all medical systems on the basis of some generally agreed upon criteria which do not necessarily privilege knowledge based upon ‘visible democratic facts’” (Nichter 1992). Ethnomedical studies presumes that the

66 Ethnomedicine “entails a study of the full range and distribution of health related experience, discourse, knowledge, and practice among different strata of a population; the situated meaning the

aforementioned has for peoples at a given historical juncture; transformations in popular health culture and medical systems concordant with social change; and the social relations of health related ideas, behaviors, and practices” (Nichter 1992: ix).

underlying coherence and practice of medical therapies are socioculturally situated, geopolitically motivated and ecologically and historically constituted. Moreover, an evolutionary medicine approach to ethnomedicine would presuppose that therapeutic interventions—much like diseases themselves—evolved and adapted over time, are aggregated and increasingly complex, bear the remnants of previous forms, and

encounter trade-offs with competing pressures and mismatches between our Environment of Evolutionary Adaptedness (EEA)⁶⁷ and modern environments.

There are many different approaches to the study of ethnomedicine⁶⁸ which is broadly conceived as the study of everyday life, perceptions of the normal and natural, the desirable and feared, and that form of embodied knowledge known as common sense as it emerges in efforts to establish or reestablish health as one aspect of well-being…how well-being and suffering are experienced bodily as well as socially, the multivocality of somatic communication, and processes of healing as they are contextualized and directed toward the person, the household, community and state, land and cosmos (Nichter 1992: x).

An evolutionary medicine approach to ethnomedicine works in conjunction with previously established types of ethnomedical inquiry: comparative studies of illness beliefs and therapeutic techniques in search of cultural universalism or cultural relativism, cross-cultural comparative physiological studies where culture is the mediating or confounding variable and studies of therapeutic efficacy where healing techniques and procedures are contextualized via content, performance, expectations and criteria of assessment (Nichter 1992:xi). This approach is necessarily biocultural and

67 The term Environment of Evolutionary Adaptedness (EEA) was originally coined by John Bowlby in Attachment and Loss (1969) and refers to the ancestral environment, including all of the adaption-relevant properties (Tooby and Cosmides 1990) and selection pressures, in which humans evolved. For further information see: Foley 1995.

68 For an excellent extended review see Nichter 1992: x-xi, which outlines twelve main forms of inquiry in ethnomedical studies: symbolic, descriptive, historical, ethnographic, continuity versus change, health care seeking and patterns of resort, illness classification, illness beliefs and reinforcing social order, the political economy of health, cultural comparative, biological comparative, and therapeutic efficacy.

demands not only serious evaluation of both the biological and cultural elements of a healing encounter, but also the interactions, dialectic relationship and dynamic process between them.

Disease-focused studies in evolutionary medicine are necessary but not sufficient.

They explain how a disease or pathogen evolved, adapted, and interacts with environmental pressures and human bodies. They elucidate how adaptations

advantageous to human fitness can make us vulnerable to sickness and disease, but they do not explain why human physiology is so susceptible to social, cultural and ritual manipulation or how psychosocial phenomena influence physiological states. Disease-focused studies do not explain cross-cultural variation in therapeutic care, and/or how therapeutic interventions influence and interact with the diseases themselves--which obfuscates attempts at comparative studies. Disease-focused studies presuppose illness categories and classifications which may or may not be cross-culturally relevant and tend to be biomedically-centric. Finally, disease-focused studies neglect the ritual and

religious health “assets” that people often draw upon to cope with their resource-deprived, conflict-heavy, unhealthy political and economic circumstances; and that can transform these “conditions that produce ill-health” (Cochrane 2007:6).

An evolutionary medicine approach focused on ethnomedical therapies, on the other hand, assesses how therapeutic behaviors evolved, adapted and interact with

environmental pressures and human bodies. It explains how pro-social adaptations that are advantageous to fitness can simultaneously make us vulnerable to social

manipulation, verbal suggestion, psychosocial stress and the negative health effects of

social pain. In addition, therapy-focused studies go further than disease models of specific endogenous physiological pathologies because they also examine the proximate mechanisms by which non-physical variables influence physiological processes.

Understanding the macro-historical, ecological and geopolitical context of the evolution and adaptation of particular medical systems is critical to comprehending cross-cultural variation in therapeutic care, and how those variations impact the course, pathology and manifestation of sickness and disease, as well as different healing techniques. Finally, ethnomedical therapy-focused studies inherently incorporate local knowledge and cultural particularity, which is a step in the right direction toward avoiding hegemonic bias.

There are many problems inherent in comparing different medical systems, especially in regard to assessing therapeutic efficacy (See Appendix: Chapter 2: 2.7.1 Problems in Therapeutic Efficacy and 2.7.2 Why Compare? for more). Yet there are also many insights not otherwise obtained. By triangulating comparisons of ethnomedical therapies via an evolutionary perspective we eliminate some of the biomedicine-centric biases and highlight techniques societies have developed to deal with universal health problems, and how these impact sickness and healing today. My hope is that situating both biomedicine and Asante indigenous healing within a biocultural evolutionary approach to

ethnomedicine will de-exoticize Asante ethnomedicine, making it more understandable, commensurable and therefore, applicable to broader problems in sickness and healing as well as providing a critical gaze upon dominant biomedical practices and current

theoretical ideologies.

Medical anthropology⁶⁹ has a long history of analyzing current medical problems from the perspective of their biocultural evolutionary history. These types of studies have focused on subjects such as the modern obesity epidemic and shown how adaptations which were naturally selected in our EEA might be maladaptive in our current ecology.

This mix of physiological and cultural adaptations, evolutionary by-products and trade-offs, and constraints inherent in complex biocultural interactions over time have

significant consequences and implications for modern health problems, such as obesity, heart disease and diabetes: the leading causes of sickness and death in the United States today. Medical models that do not take into account the ultimate interactions between phylogeny,⁷⁰ ontogeny (including how our brains and bodies develop in specific cultural contexts), mechanism, and adaptation will offer a limited understanding of the processes that affect sickness and healing (For a great example of this see Appendix: Chapter 2: 2.8 The Malaria Case Study).

Evolutionary medicine includes not only our phylogenetic past, but also the

evolutionary trajectory of pathogens, bacteria, viruses and all other plants and animals as they interact with human hosts. It also includes the impact that changes to our bodies over the course of our evolutionary trajectory (i.e., increased intellectual,⁷¹ social and

69 Medical anthropology is “a biocultural discipline concerned with both the biological and sociocultural aspects of human behavior, and particularly with the ways in which the two interacted throughout human history to influence health and disease” (Foster and Anderson 1978:2-3). “Medical anthropology is an interdisciplinary field that currently unites biological and sociocultural anthropology in terms of a biocultural evolutionary model” (Anderson 1990:20).

70 Phylogeny refers to the evolutionary history, development and interrelations of a species or taxonomic group as they change through time.

71 For a more detailed description of the development and consequences of increased intellectual complexity see Appendix: Chapter 2: 2.10.5 Increased Intellectual Complexity.

emotional complexity⁷² and physiological receptivity to social threats, etc.) and environments (i.e., larger social groups, increased psychosocial stress, obesogenic environments, technology, etc.) have on the distribution and manifestation of sickness and disease. “Most still treat culture as an external variable—as an add-on to an essentially biological system. Most fail to present a model of biocultural diversity that gives adequate weight to the cultural side of things” (Sobo 2013:8). However, “if, as I have suggested, those specific ways of acting, perceiving and knowing that we have been accustomed to call cultural are incorporated, in the course of ontogenetic development, into the neurology, musculature and anatomy of the human organism, then they are equally facts of biology” (Ingold 2001:25).

The Social Life of Placebos argues that understanding how our bodies evolved, how diseases evolved and how our medical systems interact with and even sometimes

counteract those evolutionary processes is important. These processes affect not only the

counteract those evolutionary processes is important. These processes affect not only the